Cathy Lodewijckx RN, MSc, PhD cand

University Hospitals Leuven, Belgium

Catholic University Leuven, Belgium

European Pathway Association

Belgian Society for Respiratory Nurses

DISCHARGE MANAGEMENT AND EDUCATION IN HOME OXYGEN THERAPY

Conflict of interest disclosure

I have the following, real or perceived conflicts of interest that relate to this presentation.

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I have no, real or perceived, conflicts of interest that relate to this presentation.

The intent of this disclosure is not to prevent a speaker with a conflict of interest (any significant financial relationship a speaker has with manufacturers or providers of any commercial products or services relevant to the talk) from making a presentation, but rather to provide listeners with information on which they can make their own judgments. It remains for audience members to determine whether the speaker’s interests, or relationships may influence the presentation. The ERS does not view the existence of these interests or commitments as necessarily implying bias or decreasing the value of the speaker’s presentation. Drug or device advertisement is forbidden.

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Content• Background• Non compliance in current home oxygen care• Challenges for future home oxygen therapy

Background (1)• Goal:

– PaO2 > 7.98 kPa or SaO2 > 90%– ↑↑ quality of life and survival

• Broad application: – Chronic lung diseases e.g. COPD, cystic fibrosis– Cardiac diseases– Palliative care– …

Kampelmacher, 2001; Lodewijckx, 2008; Mitrouska, 2006

Critical issue: non compliance (1)• What?

1. Non compliance to medical prescription• LTOT: ≥ 16 hours a day / continous therapy

COPD and LTOT: Compliance = 17 to 45%• Short term oxygen therapy

Oxygen use during ADL = low• Increasing oxygen flow: Carbonarcosis

2. Non compliance to precautions: burns• Smoking• Incorrect manipulation

Cullen, 2009; Cullen 2006; Edelman, 2008; Duck, 2004; Kampelmacher, 2001; Lodewijckx, 2008; Pfister, 1995; Smith, 2004

Critical issue: non compliance (2)• Important Issue?

– Insufficient effect of oxygen therapy

Condition, ADL, Quality of life, Prognosis– Hazardous effects

Carbonarcosis or burns

• Adequate home oxygen therapy:– Effective therapy– Safe administration of oxygen– comfortable administration of oxygen

Determinants (1)• Patients:

– Insufficient knowledge

Medical, practical, technical

– Impact on daily living (type of oxygen source!)

– Negative views and anxiety

– Shame and fear for social stigma

– Active smokers

– Financial factors

Cullen, 2009; Cullen 2006; Duck, 2004; Kampelmacher, 2001; Lodewijckx, 2008; Pfister, 1995; Smith, 2004

Determinants (2)• Carers: Lack of education and knowledge

Medical, practical, technical, patient impact

• Lack of coordination between primary and secondary care

– Poor discharge management

– Insufficient follow-up

=> Changing care context: ↑↑ need home oxygen therapy

– ↑↑ prevalence COPD

– Aging population

– Shift secondary care to primary care

Cullen, 2009; Cullen 2006; Duck, 2004; Kampelmacher, 2001; Lodewijckx, 2008; Lodewijckx, 2009; Pfister, 1995; Smith, 2004

Challenge 1: Patient education (1)• Who: Patient AND Family / home carer• When and who?

– At hospital: medical doctor, nurse, physiotherapists

Contact with health Care professionals– At Home: Pharmacist & Supplier, nurse & General

practitioner• Content?

– Medical information– Practical information– Technical information

Cullen, 2009; Cullen 2006; Kampelmacher, 2001; Pfister, 1995; Smith, 2004

Challenge 1: Patient education (2)Medical information (medical doctor, …)• Aim of oxygen therapy

• Effects

• Advantages

• Possible disadvantages

Technical information (supplier, …)• Correct use and maintenance of the oxygen source

• Precautions

• Contact information for questions and technical problems

Challenge 1: Patient education (3)Practical information (medical doctor, nurse, …)• Medical prescription

• Precautions• Use of oxygen source and equipment• Use of oxygen during transport, air travel and holiday• Smoking cessation• Financial aspects

• Flow: ____ L/min• Daily use: Continously; only at night, only during

exercise, if short of breath• Oxygen can be increased during exercise, if short of

breath (No/Yes: untill ____ L/min)

Challenge 1: Patient education (4)

• How to educate?

(1) Oral information;

(2) Demonstration on correct use of oxygen source and

equipment;

(3) Evaluation of understanding (checklist);

(4) Written information: Patient leaflet

Cullen, 2009; Cullen 2006; Kampelmacher, 2001; Pfister, 1995

Challenge 2: EB Practice & uniformity

• What? Best practice; Uniformity• How? EB Guidelines; national, regional level (uniformity)

1. Development:

Literature review & Experts & Congresses

2. Dessimination:

National book; national journals

National professional organizations (lectures)

3. Implementation: • Local application in different settings• Organization tools (ie transmural care pathway)• Continous follow-up of processes, outcomes

Lodewijckx, 2008; Van Haecht et al. 2006

Challenge 3: Education of carers• Who? All carers involved in oxygen therapy

– At hospital: medical doctor, nurse, physiotherapists– At Home: Pharmacist, Provider, General practitioner

• Content? Medical, practical and technical information

• How?– Access to electronic databases, websites of

(inter)national societies (search strategy)– Training by experts: national courses – local!

Challenge 4: Discharge management

< coordination > • Inform patient and family at need for home oxygen therapy

• Medical prescription of pulmonologist

• Education: patient, family, home care staf (nursing home)

• Arrangement of home oxygen therapy

Contact with oxygen suppier: social worker / family

Home delivery: Pharmacist / supplier

• Check on readiness of oxygen equipment BEFORE discharge

• Arrange oxygen therapy during transport if necessary

Challenge 5: Follow-up• Re-evaluation by pulmonologist within 1-2 months after start

Effect of therapy: Clinical condition, arterial blood gases

Need for further therapy / adjustment of therapy

Correct use of oxygen therapy

Motivation & compliance

• Ongoing follow-up by GP and home care nurseSystematical assessment: detect problems; refer patients

• Re-evaluation by pulmonologist every 6 months / ↓ conditionCompliance to prescription, motivation, effectShort-oxygen therapy: re-evaluation 3-4 months after start

Cullen, 2009; Cullen 2006; Edelman, 2008; Duck, 2004; Kampelmacher, 2001; Lodewijckx, 2008; Pfister, 1995; Smith, 2004>>ADL, quality of life, readmission, suvival<<

Challenge 6: Research• What do we need to know?

– What & where is need for interventions?– What are (cost)-effective and feasable interventions?

What is impact on outcomes?

=> Gouvernment: sensibilisation; financial resources?• Indicators?

– Actual prevalence / compliance in patients– Process outcomes: actual performance of health carers – Patient outcomes: clinical, service– Financial outcomes (cost-effectiveness)– Impact of specific interventions: Education, follow-up

Challenges for future Home oxygen therapy

Safe, comfortable and effective

Home oxygen therapy• Adequate patient & family education• EB Practice & uniformity: EB Guidelines: development,

dessimination , local implementation (care pathways)• Adequate education of carers• Organization of care:

– Discharge management – Follow-up

• Research: need & effectiveness of interventions